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After the mucosa and muscularis of the protruding segment have been completely divided, traction is maintained downward on the cuff of incised mucosa and muscularis (Figure 6). Any attachments between the bowel wall and the underlying segment are divided with the electrocoagulant unit or sharp knife, and all bleeding points are controlled. This cuff is pulled off easily and results in a segment twice as long as the original protrusion (Figure 7). The bowel wall is not amputated at this time, but downward traction is maintained as an attempt is made to identify the prolapsed pouch of Douglas (Figure 7). The resection may be started in the midline anteriorly and continued upward through the fat until the glistening wall of the peritoneum is identified. The peritoneum is gently opened (Figure 8), and the pouch of Douglas is explored with the examining finger. Any attachments between the small bowel or adnexa in the female should be separated to ensure freeing of as much of the pouch of Douglas as possible and to permit mobilization of the redundant rectosigmoid into the wound.

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After the peritoneum is opened, the presenting intestine lying on the posterior side of the sliding hernia is grasped with forceps to determine how much mobile large intestine will require amputation to correct the tendency toward recurrent prolapse. The peritoneal opening should be extended laterally to either side. The blood supply, surrounded by a thick layer of fatty tissue, is usually identified posteriorly and on the right side of the presenting intestines (Figure 9). Half-length forceps and the surgeon's index finger are used as blunt dissectors until the mesentery to this segment of the bowel has been separated without injuring the bowel wall itself. At least three half-length clamps are applied to ensure a safe double ligation with 0 absorbable suture (Figure 10). The most proximal one of these sutures should be of the transfixing type, since the tissues are under some tension, and bleeding may develop unless the contents of these clamps are tied securely. No effort should be made to strip the bowel from the mesentery; however, it may be necessary to reapply clamps from either side, as well as in the midline posteriorly, until all the redundant large intestine has been pulled freely into the wound.

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After the blood supply has been ligated and as much ...

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